Utilization review nurse jobs in Cranston, RI

Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary The Medicare UM Case Manager, RN performs utilization management activities primarily for Medicare Advantage, including review of authorizations for home care, high tech radiology, outpatient, inpatient, and post-acute services. The Medicare UMCM reviews the medical necessity of authorization requests using NCD, LCD, Medicare Benefit Policy Manual, medical policies, and InterQual criteria. Qualifications Education Associate's Degree Nursing required; Bachelor's Degree Nursing preferred Licenses and Credentials Massachusetts Registered Nurse license required Basic Life Support [BLS Certification] Certification preferred Experience At least 2-3 years of utilization management strongly preferred Experience applying National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and Medicare Benefit Policy Manual preferred InterQual experience preferred Knowledge, Skills, and Abilities Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times. Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems. Ability to establish strong rapport and relationships with patients and staff. Proficient in Microsoft Office and industry-related software programs. Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions. Ability to maintain client and staff confidentiality. Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care. Knowledge of Healthcare and Managed Care preferred. Additional Job Details (if applicable) Working Conditions This is a remote role that can be done from most US states Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $58,656.00 - $142,448.80/Annual Grade 98TEMP At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at **************. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary The UMCM will utilize clinical knowledge to analyze, assess, and render approval decisions, to determine the need for physician review as well as complete determinations following physician review. The ideal candidate will have prior authorization (outpatient review) experience in a managed care setting with Medicaid/MassHealth knowledge. Principal Duties and Responsibilities: * Expertise in clinical review for prospective, concurrent, retrospective utilization management reviews utilizing Interqual , company policies and procedures, and other resources as determined by review, including physician reviews as needed for all lines of business as per departmental needs * Review authorization requests for medical services, including making initial eligibility and coverage determinations, screening for medical necessity appropriateness, determining if additional information is required, and referral to correct programs within Mass General Brigham Health Plan as needed. * Manage incoming requests for procedures and services including patient medical records and related clinical information. * Strong working knowledge of commercial, self-insured, fully insured and limited network plans. * Adherence to program, departmental and organizational performance metrics including productivity. * Excellent verbal and written communication skills. * Excellent problem solving and customer service skills. * Would need to be available for "on call" for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire. * Must be self-directed and highly motivated with an ability to multi-task. * Develop and maintain effective working relationships with internal and external customers * Hold self and others accountable to meet commitments. * Sound decision-making and time management skills. * Proactive in areas of professional development, personally and for the department. * Persist in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise. * Build strong relationships and infrastructures that designate Mass General Brigham Health Plan as a people-first organization. * Proficient with Microsoft Word, Excel, Outlook, McKesson InterQual , Outlook, SharePoint, PC based operating system, and web-based phone system. Qualifications Education * Associate's Degree Nursing required or Bachelor's Degree Nursing preferred Licenses and Credentials * Massachusetts Registered Nurse (RN) license required Experience * At least 2-3 years of utilization review experience is highly preferred * Experience using Interqual or Milliman is highly preferred * At least 1-2 years of experience in a payer setting is highly preferred * At least 1-2 years of experience in an acute care setting is highly preferred Knowledge, Skills, and Abilities * Demonstrate Mass General Brigham Health Plan's core brand principles of always listening, challenging conventions, and providing value * Strong aptitude for technology-based solutions. * Embrace opportunities to take the complexity out of how we work and what we deliver. * Listen to our constituents, learn, and act quickly in our ongoing pursuit of meaningful innovation * Current in healthcare trends. * Ability to inject energy, when and where it's needed. * Exercise self-awareness; monitor impact on others; be receptive to and seek out feedback; use self-discipline to adjust to feedback. * Be accountable for delivering high-quality work. Act with a clear sense of ownership. * Bring fresh ideas forward by actively listening to and working with employees and the people we serve. * Communicate respectfully and professionally with colleagues * Strong EQ; exercises self-awareness; monitors impact on others; is receptive to and seeks out feedback; uses self-discipline to adjust to feedback. Additional Job Details (if applicable) Working Conditions * Would need to be available for "on call" for a minimum of once per month with the possibility of that increasing depending on staff availability; Approximately 6 months after hire. * This is a remote role with occasional onsite team meetings in Somerville, MA. Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $58,656.00 - $142,448.80/Annual Grade 98TEMP At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at **************. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

Benefits: Direct Deposit Weekly Pay Competitive salary Inpatient RN - Utilization Review Nurse (Behavioral Health) - Cambridge, MA Schedule: Day Shift, Monday-Friday, 8:30 AM - 5:00 PM Pay: $72/hour Job Summary: We are seeking a skilled Inpatient RN Utilization Review Nurse to join our behavioral health team in Cambridge. This role focuses on acute care review and utilization management to ensure high-quality patient care. Requirements: Must be a local candidate within 50 miles of Cambridge, MA Acute care experience required Experience with InterQual criteria EMR experience required (EPIC preferred) Strong clinical judgment and utilization review skills Responsibilities: Review and evaluate patient care for appropriateness and efficiency Collaborate with interdisciplinary teams to support patient care and discharge planning Ensure compliance with hospital policies and clinical guidelines Apply now to join a team dedicated to delivering exceptional behavioral health care. Compensation: $72.00 per hour Great jobs. Great company. Great community of caregivers. At Aura Staffing Partners, we know that partnering with you to find the right opportunity in healthcare is just the beginning. We don't leave you high and dry, instead we help you grow even brighter with quarterly reviews, continued training and plenty of communication.

**Become a part of our caring community and help us put health first** Conviva Care Solutions is seeking a RN who will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review criteria and who is interested in being part of a team that focuses on excellent service to others. **Use your skills to make an impact** **Required Qualifications** + Active unrestricted RN license with the ability to obtain Compact Nursing License + A minimum of three years clinical RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to work independently and within a team setting + Willing to work in multiple time zones + Strong written and verbal communication skills + Attention to detail, strong computer skills including Microsoft office products + Ability to work in fast paced environment + Ability to form positive working relationships with all internal and external customers **Preferred Qualifications** + Education: BSN or bachelor's degree in a related field + Experience with Physical Therapy, DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/Medicare + Current nursing experience in Hospital, SNF, LTAC, DME or Home Health. + Bilingual **Alert** Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from ******************** with instructions on how to add the information into your official application on Humana's secure website. **Interview Format - HireVue** As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. **Work-At-Home Requirements** To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: + At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested. + Satellite, cellular and microwave connection can be used only if approved by leadership. + Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. + Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. + Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. **Benefits** Humana offers a variety of benefits to promote the best health and well-being of our employees and their families. We design competitive and flexible packages to give our employees a sense of financial security-both today and in the future, including: + Health benefits effective day 1 + Paid time off, holidays, volunteer time and jury duty pay + Recognition pay + 401(k) retirement savings plan with employer match + Tuition assistance + Scholarships for eligible dependents + Parental and caregiver leave + Employee charity matching program + Network Resource Groups (NRGs) + Career development opportunities Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 12-25-2025 **About us** About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of CenterWell Senior Primary Care, Conviva's innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health - addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being. About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation's largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first - for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one. **Equal Opportunity Employer** It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. 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· Participates in the development and ongoing implementation of QM Work Plan activities. · Improve quality products and services, by using measurement and analysis to process, evaluate and make recommendations to meet QM objectives Responsibilities: · Reviews documentation and evaluates Potential Quality of Care issues based on clinical policies and benefit determinations. · Considers all documented system information as well as any additional records/data presented to develop a determination or recommendation. · Data gathering requires navigation through multiple system applications. · Staff may be required to contact the providers of record, vendors, or internal Aetna departments to obtain additional information. · Evaluates documentation/information to determine compliance with clinical policy, regulatory and accreditation guidelines. · Responsible for the review and evaluation of clinical information and documentation. · Reviews documentation and interprets data obtained form clinical records or systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues. · Works Potential Quality of Care cases across all lines of business (Commercial and Medicare). · Independently coordinates the clinical resolution with internal/external clinician support as required. · Processes and evaluates complex data and information sets -Converts the results of data analysis into meaningful business information and reaches conclusions about the data · Prepares and completes QM documents based on interpretation and application of business requirements · Documents QM activities to demonstrate compliance with business, regulatory, and accreditation requirements · Assists in the development and implementation of QM projects and activities · Accountable for completing and implementation of QM Work Plan Activities Experience: · 3+ years of experience as an RN · 1+ years of inpatient hospital experience · Registered Nurse in state of residence · Must have prior authorization utilization experience · Able to work in multiple IT platforms/systems Skills: · MUST HAVE MEDCOMPASS or ASSURECARE exp. · MUST HAVE MANAGED CARE exp and Medicare/Medicaid knowledge. · MUST HAVE UM experience, inpatient utilization management review. · MUST HAVE 1 YEAR OF UTILIZATION MANAGEMENT EXP, pref. knowledge of Milliman/MCG. · MUST HAVE 6 months of Prior Authorization. Education: · Active and unrestricted RN licensure in state of residence **About US Tech Solutions:** US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit *********************** (*********************************** . US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Formulary Strategy & Utilization Review Pharmacist Shape the drug benefit landscape-analyze and optimize medication use. Key Responsibilities: Review prescribing trends and propose cost-saving alternatives. Maintain evidence-based formularies across multiple payers. Conduct retrospective DUR and prepare stakeholder reports. Qualifications: PharmD with managed care, DUR, or pharmacy benefit experience. Strong Excel/data analytics background preferred. Understanding of clinical guidelines and P&T processes. Why Join Us? Join a top-tier managed care team Hybrid flexibility Strategic and data-driven focus

Behavioral Health Community Partnership (BHCP) Nurse Case Manager Department: Social Services Supervisor: Director of Nursing Status/Hours Per Week: Non-exempt / 35 hours Pay Range: The expected base pay for the position is $36-$65.02 per hour and may be increased based on other factors, such as language, certifications, etc. Primary Function: The Behavioral Health Community Partnership Nurse Case Manager [BHCP RN Case Manager] functions under the supervision of the Director of Nursing and overall guidance and consultation with the Medical Director and other Primary Care Providers to conduct patient monitoring, tracking, and provide ongoing care coordination and support to patients with behavioral health issues that are enrolled in BHCP. The BHCP RN Case Manager ensures patients' adequate linkages with behavioral health counseling, all levels of substance use care, including medication assisted treatment, and chronic pain management care. Duties & Responsibilities: * Receive and maintain a log of all patients enrolled in BHCP, and ensure adequate follow up and care coordination. * Serve as Clinical Care Manager for enrollees referred to the team, participating in the assessment, care planning, and on-going BHCP service provision specified in program protocols and policies. * Review and approve Comprehensive Health Assessments for members including performing medication reconciliations. * Make patient referrals to behavioral health, and human services providers at the Health Center for needed services such as primary care and other substance use and mental health care. * Make "warm handoffs" and coordinate support to needed services at external organizations including hospitals, substance use treatment programs, etc. * Follow up with members post-discharge to ensure members are seen by a Primary Care provider in a timely manner. * Monitor and track patients including progress in their treatment plan and update PCPs and other members of the team. * Participate in multi-disciplinary team meetings, utilization review, and program planning. * Participate in consultation, sharing of resources and best practices with other Riverside Community Partner teams.

Job Description Summary: SMOC Behavioral Healthcare is a division of SMOC that provides substance abuse and mental health outpatient services to individuals, children and families. This position will coordinate billing and monitor utilization review for the Clinic and Residential Recovery Programs. Candidates must possess at least 2-3 years' experience billing 3rd party insurance, work with Department of Public Health contracts. Why Work for SMOC? Paid Time Off: All full-time employees can accrue up to 3 weeks of vacation, and 2 weeks of sick time and are eligible for 12 paid holidays during their first year of employment. Employer-paid Life Insurance & AD&D and Long-Term Disability for full-time employees. Comprehensive Benefits Package including Medical Plans through Mass General Brigham with an HRA Employer cost-sharing program, Dental Plans with Orthodontic Coverage, and EyeMed Vision Insurance available to full-time employees. 403(B) Retirement Plan with a company match starting on day one for all full-time and part-time employees. Additional voluntary benefits including; Term and Whole Life Insurance, Accident Insurance, Critical Illness, Hospital indemnity, and Short-Term Disability. Flexible Spending Accounts, Dependent Care Accounts, Employee Assistance Program, Tuition Reimbursement and more. Primary Responsibilities: Interface with the billing subcontractor. Work hand in hand with representatives from the billing contractor and the clinic front office to make adjustments in the health record to ensure all activities are billable to all payors. Ensure all client payor information and authorizations are entered into the electronic health record. Reconcile and resolve issues related to claims submissions, research and resolve eligibility issues, including contact with clients to inform of eligibility loss. Ensure all new and ongoing prior authorizations are entered for the Outpatient Clinic programs, Residential Recovery Programs. Ensure all billing to Department of Public Health is entered accurately and in a timely fashion, for the RRS and outpatient clinic programs. Review denials and partially paid claims and resolve discrepancies. Assist in resolving overdue claim problems. Run reports and gather data as needed for financial and operating reports. Recommend write-off and process in billing system as directed. Ensure compliance with program/department, agency and/or funder requirements, as well as, SMOC policies & procedures. Other duties as assigned. Knowledge and Skill Requirements: Associates Degree preferred or relevant experience Medical and/or Mental Health third party billing experience Experience with third party billing denial and resolution process Must have ability to handle multiple and changing priorities and meet deadlines Organizational Relationship: Directly reports to Operations Director. Indirectly reports to Director of Residential Recovery Programs. Direct reports of this position are none. Physical Requirement: Ability to ascend and descend stairs Ability to see and read Ability to lift up to 10lbs Dress is business casual Working Conditions: As part of the responsibilities of this position, the Utilization Management Coordinator will have direct or incidental contact with clients served by SMOC in various programs funded or administered through the Executive Office of Health and Human Services. Remote Work Option: Remote work is permissible in some positions at SMOC depending on the key functions and responsibilities. The Compliance Officer position is eligible to work from home 0-60% of the week in scheduling coordination with the department manager. Monday through Friday: 9:00AM - 5:00PM. Includes a 1-hour unpaid lunch break. 35 Hours per week.

Job Description Provides nursing care for pulmonary patients in the ambulatory setting -primarily via telephone and secure messaging, rather than through direct patient contact. The nurse is an integral member of the pulmonary care team in helping patients achieve optimal lung health and in managing chronic conditions effectively - through assessment, planning, treatment and evaluation/re-evaluation. Provides safe, knowledgeable, compassionate, individualized and goal-directed nursing care to patients of the division of Pulmonary, Critical Care & Sleep Medicine at Brown Medicine. PRINCIPAL DUTIES AND RESPONSIBILITIES: Consistently applies the Brown Medicine values of patient care priority, dignity, collaboration, integrity and quality in support of the Brown Medicine mission to deliver compassionate, high-quality patient care, research excellence and outstanding physician education. Is responsible for knowing and acting in accordance with the Brown Medicine Compliance Program and Code of Conduct. Consistently practices the Brown Medicine Customer Service Standards. Provide nursing triage, assessment and education to patients via nurse visits, telephone interactions and secure messaging Manage patient needs including medication management, post procedure instructions and care coordination. Serve as a liaison to patients, family members and referring providers with guidance from pulmonary providers. Acts as patient advocate in the coordination of patient care. Demonstrates understanding and interpretation of diagnostic measures such as lab tests. Identifies goals for the individual patient and communicates these goals to the appropriate care team member involved in the patient's care. Reports and documents information accurately and in a timely manner Seeks guidance, direction and assistance where needed. Adheres to BMED Policy and Procedures at all times and is an active participant in the QI program Adheres to required infection prevention measures and environmental safety practices. Participates in staff meetings and In-services as required/requested. Demonstrates flexibility in patient care, assignment, schedule. Delegate tasks and direct the activities of unlicensed care providers (schedulers, Medical Assistants and Staff Assistants). Utilizing supplies, equipment and resources to contains costs without compromising delivery of care Performs other duties as assigned KNOWLEDGE, SKILLS & ABILITIES REQUIRED: Good command of the English language, both verbal and written. Equivalent mastery of the Spanish language is preferred but not required. Ability to work well with physicians, APPs, employees, patients, families and others. Pulmonary, Nurse Triaging, and/or Ambulatory experience required. EDUCATION AND EXPERIENCE Graduate of a Professional School of Nursing Current state licensure as a registered nurse (RN) or licensed practical nurse (LPN) Current certification in BLS Evidence of continuing education WORKING CONDITIONS AND PHYSICAL REQUIREMENTS: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation(s) may be made to enable individuals with disabilities to perform the essential functions. May have exposure to patients with communicable diseases, blood and body fluids May have exposure to hazardous equipment/gases/chemical agents INDEPENDENT ACTION: Ability to act independently without direct supervision. SUPERVISORY RESPONSIBILITY: None. Reports to: Pulmonary Medical Director/Physician Lead & Practice Manager Employees are required to be vaccinated against Covid as a condition of employment, subject to accommodation for medical exemptions. We value a diverse, talented workplace and seek colleagues who strive to better understand systemic barriers as it affects patient care and our academic institutions. Brown Medicine welcomes nominations and applications from all individuals with varied experiences, perspectives, abilities, identities, and backgrounds to enrich our clinical, research, training and service missions.

ECMO, which stands for extracorporeal membrane oxygenation, is an advanced technology that functions as a replacement for a critically ill child's heart and lungs. It's used to support a child who is awaiting surgery, or to give a child's vital organs time to recover from heart surgery or disease. Boston Children's Hospital is home to one of the largest pediatric ECMO programs in the world; we provide services to critically ill children in the New England region, and to those who are referred from other states and internationally. We serve between 50 and 60 patients with severe respiratory or cardiac problems each year. Since its establishment in 1984, the ECMO Program has supported more than 900 children. Throughout the 20-year history of the ECMO Program at Boston Children's, we have gained considerable expertise, minimized complications, and increased its success rate for survival to 60 percent, higher than the national average of around 40 percent. Key Responsibilities: * Plans and organizes daily clinical and administrative responsibilities within the designated unit/program/service. * Develops, recommends, and implements internal standards, policies, and procedures to improve quality of patient care in collaboration with ECMO clinical leadership. * Develops and provides staff education/development programs in collaboration with unit specific nursing leadership. * Performs clinical review of inpatients who are either at risk of requiring ECMO or have been exposed to ECMO. * Collects clinical data relevant to patient outcomes and adverse events associated with critical illness and/or ECMO. * Works collaboratively with a multidisciplinary health care team to optimize patient care outcomes. * 40 hours per week. Minimum Qualifications Education: * A Bachelor's degree in nursing. Experience: * 4-5 years of pediatric critical care or pediatric cardiac critical care RN experience required. * Excellent attention to detail and the ability to adhere to stringent care protocols and documentation standards. * Strong communication skills and the ability to work collaboratively in a team-oriented clinical environment with liaison with strong quality-improvement team. Licensure/ Certifications: * Current Massachusetts license as a Registered Nurse (RN) The posted pay range is Boston Children's reasonable and good-faith expectation for this pay at the time of posting. Any base pay offer provided depends on skills, experience, education, certifications, and a variety of other job-related factors. Base pay is one part of a comprehensive benefits package that includes flexible schedules, affordable health, vision and dental insurance, child care and student loan subsidies, generous levels of time off, 403(b) Retirement Savings plan, Pension, Tuition and certain License and Certification Reimbursement, cell phone plan discounts and discounted rates on T-passes. Experience the benefits of passion and teamwork.

Under direction of Head Nurse and/or Program management, plays a leadership role in the investigation and follow-up of communicable disease cases/outbreaks or other situations of public health concern. Performs and oversees communicable disease surveillance, prevention and control measures according to protocols for cases/outbreaks as assigned. In conjunction with other Division staff, identifies patterns of communicable diseases and related risk factors, and provides health education and outreach as needed for communicable disease prevention and control. This nursing leadership position ensures high quality nursing practice within the CDC Division, by overseeing clinical nursing activities and directing and evaluating the professional practice of nurses, according to established standards of care. This position is also expected to work with the nursing leadership to develop standard operating procedures and workflows for case and outbreak investigations and contact tracing efforts. Investigates and provides care and follow-up of contagious diseases including COVID-19. Vaccinates against contagious diseases including COVID-19. In conjunction with other Division staff, identifies patterns of communicable diseases and related risk factors, and provides health education and outreach as needed for communicable disease prevention and control. Assists with development of data collections tools and ensures complete and accurate collection of data. Supervises subordinates as required. Assists in orientation of new staff, program visitors and in staff development programs. Identifies or develops resources as needed for case or outbreak follow-up. Provides nursing support for CDC Division activities, including vaccine and other clinics or other projects or activities as needed. Provides nursing services at the TB Clinic, including phlebotomy, patient assessment, patient/family/significant other education, medication monitoring, and skin testing. Participates in special projects and initiatives as requested and acts as clinical back-up for special projects. Participates in staff conferences, research activities, meetings with community based or other agencies as requested. Plays a key role in communicable disease related epidemiologic activities. Plays a key role in providing education and outreach on communicable disease issues to health care providers, agencies, and community groups throughout the city. Acts as a resource on communicable disease related issues for division staff, providers, and community groups. Collaborates with others throughout the Division to ensure public health preparedness for bioterrorism and other communicable diseases. May be required to perform duties of other CD or TB nurses. Performs other duties as required. Works to help BPHC advance as an antiracist organization by meeting or exceeding the standards set by the BPHC Anti-Racism Policy.

Full-time, Part-time Description Job Title: Wellness Nurse Hours: Per Diem The Resident Care Nurse is responsible for assisting the Resident Care Director with the overall implementation, delivery and coordination of Resident Care services at the Community. Nurse will also assist in monitoring the medication management program. Duties and Responsibilities: The following essential functions are the fundamental job duties of the position to be completed with or without appropriate reasonable accommodation. • Assist in supervising the medication program and assisting the residents with self-administration of their medication. • Assist residents with Activities of Daily Living and Independent with Activities of Daily Living as needed. • Maintain positive relations with residents, families and physicians. • Report any significant incidents and/or changes in the residents needs to the Executive Director/Resident Care Director. • Assist in the completion of resident assessments and services plans. • Assist in the training of assisted living staff and participates in orientation of new staff. • Attend and participates in scheduled in-service programs, training programs and staff meetings. • Assist with scheduling and staffing of Resident Care Assistants • RN will maintain GAFC. • May perform other duties as assigned. Requirements Minimum Qualifications: • Registered Nurse/Licensed Practical Nurse/Licensed Vocational Nurse with a current license in good standing. • Certification or licensed per state guidelines. • Must successfully complete all HallKeen • Community specified training programs. • Able to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Able to deal with problems involving a few concrete variables in standardized situations. • Able to work various schedules and shifts as needed. • Required Behavior: • Appearance is neat, clean, and according to dress code. • Able to demonstrate a high level of service delivery; does what is necessary to ensure customer satisfaction; deals with service failures and prioritizes customer needs. • Able to clearly present information through the spoken word; reads and interprets complex information; talks with residents, family members and customers; listens well. • Able to communicate with others in a warm and helpful manner while simultaneously building credibility and rapport. • Able to work cooperatively with a group of people to achieve goals and objectives. • Able to be tactful; maintains confidences, and fosters an ethical work environment; prevents inappropriate behavior by coworkers; gives proper credit to others; handles all situations honestly. • Able to keep an open mind and change opinions on the basis of new information; performs a variety tasks and changes focus quickly as demands change; manages transitions effectively from task to task; adapts to varying customer needs. Physical Demands: • Physically able to move at least 50 lbs. without assistance. • Physically able to bend, reach, and work in small areas. • Physically able to push and pull equipment and furnishings. • Physically able to stand for long periods of time.

Information Posting Number SF02079 Job Title Coordinator, Nursing Services Position Number 107085 FTE 1.00 FLSA Exempt Position Type Professional Staff Union PSA/NEA - Professional Staff Assoc Pay Grade Level Grade Level: 16 Pay Grade Range Anticipated Hiring Salary $95,000 - $100,000 (is prorated to reflect the academic year 20-pay period work schedule). Status Full-time, Academic Year, Permanent Department Information Department Health Svs. Contact(s) Please note: Job applications must be submitted directly online only at: (********************* Contact Phone/Extension Contact Email Physical Demands Campus Location Kingston Grant Funded No Extension Contingency Notes Summary The search will remain open until the position has been filled. First consideration will be given to applications received by November 3, 2025. Applications received after November 3, 2025 may be reviewed depending on search progress and needs but are not guaranteed full consideration. _______________________________________________________________________________________________________ About URI: The University of Rhode Island enrolls approximately 17,000 students across its graduate and undergraduate programs and is the State's flagship public research university, as well as the land grant and sea grant university, for the state of Rhode Island. The main campus is located in the historic village of Kingston, and the Bay Campus is located in Narragansett. Both campuses are near major beaches in a beautiful coastal community. URI is just 30 minutes from Providence, RI and within easy reach of Newport, Boston, and New York City. _________________________________________________________________________________________________ POSITION SUMMARY: Responsible for the supervision of all nursing services within Health Services. Duties and Responsibilities KEY RESPONSIBILITIES: Develop, document, and maintain nursing policies and procedures which ensure compliance with University, state, and federal regulations, as well as meet the standards of the American College Health Association and the Joint Commission. Monitor performance for compliance with established policies and procedures to ensure effective operation. Evaluate opportunities for improvement in operations and present proposals for innovation or revision. Perform nursing duties consistent with RI state licensure. Establish, document, and monitor an infection control program consistent with regulations (OSHA) and accreditation standards (JC). Coordinate operation of clinical areas to include oversight of stocking of exam rooms, ordering of medical supplies, and maintenance/calibration/safety testing of all medical devices. Develop, document, and coordinate an employee orientation program consistent with regulations and accreditation standards. Participate in a broad variety of meetings that include leadership team, safety and infection control and clinical staff. Chair regular department and special function meetings. Schedule nurses and develop and implement appropriate staffing patterns. Develop and implement continuing nursing education programs which are recognized by the Rhode Island State Nurses Association. Coordinate nursing services with other departments within Health Services. Initiate job descriptions and assignment descriptions for all nursing personnel. Interview and evaluate applications for nursing vacancies. Relate to various union contracts and function as liaison with the various units. Administer the Collective Bargaining Agreements as they relate to nursing services. Make recommendations to the Director regarding the Nursing Department's budget. OTHER DUTIES AND RESPONSIBILITIES: Function as nursing liaison with College of Nursing. Prepare and present required reports regarding the Nursing Department and its activities to the Director. Perform other duties as required. LICENSES, TOOLS, AND EQUIPMENT: Valid R.I. Registered Nurse's License prior to appointment. Required Qualifications REQUIRED: 1. Master's degree in Nursing Administration or similar discipline. 2. Valid R.I. Registered Nurses License prior to appointment. 3. Minimum of five years' nursing practice (within the last 10 years). 4. Minimum of three years of administrative responsibility and supervisory experience. 5. Strong interpersonal and verbal communication skills. 6. Proficiency in written communication skills. 7. Ability to communicate effectively with faculty and administrative staff members on assigned work and related subjects. 8. Ability to interpret institutional policies, plans, objectives, rules and regulations, and to communicate the interpretation to others. 9. Ability to prepare and present detailed studies and reports, and to make recommendations concerning the substance of the studies and reports. 10. Ability to work with diverse groups/populations. Preferred Qualifications PREFERRED: 1. Experience in a college health setting. ______________________________________________________________________________________________________ The University of Rhode Island is an equal opportunity employer. It is the policy of the University of Rhode Island to provide reasonable accommodation when requested by a qualified applicant or employee with a disability. Environmental Conditions This position is not substantially exposed to adverse environmental conditions. Posting Date 10/20/2025 Closing Date Special Instructions to Applicants Please attach the following 2 (PDF) documents to your online Employment Application: (#1) Cover letter. (#2) Curriculum Vitae. Note: References will be upon request by the committee. Quicklink for Posting ***********************************

Department Child Development: Day Camp Employment Type Seasonal - Full Time Location Ponkapoag Workplace type Onsite Compensation $25.00 - $35.00 / hour Key Responsibilities Skills, Knowledge and Expertise Benefits About YMCA of Greater Boston The YMCA of Greater Boston is the largest social services provider in Massachusetts. Through our network of facilities and program sites, the YMCA provides health and wellness programming, child care, summer camp, youth sports, and teen leadership programs, as well as work-force development and community outreach. The YMCA of Greater Boston is committed to a policy of nondiscrimination and equal opportunity for all employees and qualified applicants without regard to race, color, religious creed, protected genetic information, national origin, ancestry, sex, sexual orientation, gender identity, age, disability, or veteran's status.

Site: Mass General Brigham Health Plan Holding Company, Inc. Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham. Job Summary The Medicare UM Case Manager, RN performs utilization management activities primarily for Medicare Advantage, including review of authorizations for home care, high tech radiology, outpatient, inpatient, and post-acute services. The Medicare UMCM reviews the medical necessity of authorization requests using NCD, LCD, Medicare Benefit Policy Manual, medical policies, and InterQual criteria. Qualifications Education * Associate's Degree Nursing required; Bachelor's Degree Nursing preferred Licenses and Credentials * Massachusetts Registered Nurse license required * Basic Life Support [BLS Certification] Certification preferred Experience * At least 2-3 years of utilization management strongly preferred * Experience applying National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and Medicare Benefit Policy Manual preferred * InterQual experience preferred Knowledge, Skills, and Abilities * Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times. * Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems. * Ability to establish strong rapport and relationships with patients and staff. * Proficient in Microsoft Office and industry-related software programs. * Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions. * Ability to maintain client and staff confidentiality. * Understanding of diagnostic criteria for dual conditions and the ability to conceptualize modalities and placement criteria within the continuum of care. * Knowledge of Healthcare and Managed Care preferred. Additional Job Details (if applicable) Working Conditions * This is a remote role that can be done from most US states Remote Type Remote Work Location 399 Revolution Drive Scheduled Weekly Hours 40 Employee Type Regular Work Shift Day (United States of America) Pay Range $58,656.00 - $142,448.80/Annual Grade 98TEMP At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package. EEO Statement: Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at **************. Mass General Brigham Competency Framework At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.

**Become a part of our caring community and help us put health first** Conviva Care Solutions is seeking a RN who will collaborate with other health care givers in reviewing actual and proposed medical care and services against established CMS Coverage Guidelines/NCQA review criteria and who is interested in being part of a team that focuses on excellent service to others. **Use your skills to make an impact** **Required Qualifications** + Active unrestricted RN license with the ability to obtain Compact Nursing License + A minimum of three years clinical RN experience; + Prior clinical experience, managed care experience, **OR** utilization management experience + Demonstrates Emotional Maturity + Ability to work independently and within a team setting + Willing to work in multiple time zones + Strong written and verbal communication skills + Attention to detail, strong computer skills including Microsoft office products + Ability to work in fast paced environment + Ability to form positive working relationships with all internal and external customers **Preferred Qualifications** + Education: BSN or bachelor's degree in a related field + Experience with Physical Therapy, DME, Cardiac or Orthopedic procedures + Previous experience in utilization management within Insurance industry + Previous Medicare Advantage/Medicare + Current nursing experience in Hospital, SNF, LTAC, DME or Home Health. + Bilingual **Alert** Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from ******************** with instructions on how to add the information into your official application on Humana's secure website. **Interview Format - HireVue** As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule. **Work-At-Home Requirements** To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: + At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested. + Satellite, cellular and microwave connection can be used only if approved by leadership. + Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense. + Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. + Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. **Benefits** Humana offers a variety of benefits to promote the best health and well-being of our employees and their families. We design competitive and flexible packages to give our employees a sense of financial security-both today and in the future, including: + Health benefits effective day 1 + Paid time off, holidays, volunteer time and jury duty pay + Recognition pay + 401(k) retirement savings plan with employer match + Tuition assistance + Scholarships for eligible dependents + Parental and caregiver leave + Employee charity matching program + Network Resource Groups (NRGs) + Career development opportunities Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required. **Scheduled Weekly Hours** 40 **Pay Range** The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $71,100 - $97,800 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. **Description of Benefits** Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities. Application Deadline: 12-25-2025 **About us** About Conviva Senior Primary Care: Conviva Senior Primary Care provides proactive, preventive care to seniors, including wellness visits, physical exams, chronic condition management, screenings, minor injury treatment and more. As part of CenterWell Senior Primary Care, Conviva's innovative, value-based approach means each patient gets the best care, when needed most, and for the lowest cost. We go beyond physical health - addressing the social, emotional, behavioral and financial needs that can impact our patients' well-being. About CenterWell, a Humana company: CenterWell creates experiences that put patients at the center. As the nation's largest provider of senior-focused primary care, one of the largest providers of home health services, and fourth largest pharmacy benefit manager, CenterWell is focused on whole-person health by addressing the physical, emotional and social wellness of our patients. As part of Humana Inc. (NYSE: HUM), CenterWell offers stability, industry-leading benefits, and opportunities to grow yourself and your career. We proudly employ more than 30,000 clinicians who are committed to putting health first - for our teammates, patients, communities and company. By providing flexible scheduling options, clinical certifications, leadership development programs and career coaching, we allow employees to invest in their personal and professional well-being, all from day one. **Equal Opportunity Employer** It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. Centerwell, a wholly owned subsidiary of Humana, complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. 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Utilization Review Pharmacist Shape the drug benefit landscape-analyze and optimize medication use. Key Responsibilities: Review prescribing trends and propose cost-saving alternatives. Maintain evidence-based formularies across multiple payers. Conduct retrospective DUR and prepare stakeholder reports. Qualifications: PharmD with managed care, DUR, or pharmacy benefit experience. Strong Excel/data analytics background preferred. Understanding of clinical guidelines and P&T processes. Why Join Us? Join a top-tier managed care team Hybrid flexibility Strategic and data-driven focus

Summary: SMOC Behavioral Healthcare is a division of SMOC that provides substance abuse and mental health outpatient services to individuals, children and families. This position will coordinate billing and monitor utilization review for the Clinic and Residential Recovery Programs. Candidates must possess at least 2-3 years' experience billing 3 rd party insurance, work with Department of Public Health contracts. Why Work for SMOC? Paid Time Off: All full-time employees can accrue up to 3 weeks of vacation, and 2 weeks of sick time and are eligible for 12 paid holidays during their first year of employment. Employer-paid Life Insurance & AD&D and Long-Term Disability for full-time employees. Comprehensive Benefits Package including Medical Plans through Mass General Brigham with an HRA Employer cost-sharing program, Dental Plans with Orthodontic Coverage, and EyeMed Vision Insurance available to full-time employees. 403(B) Retirement Plan with a company match starting on day one for all full-time and part-time employees. Additional voluntary benefits including; Term and Whole Life Insurance, Accident Insurance, Critical Illness, Hospital indemnity, and Short-Term Disability. Flexible Spending Accounts, Dependent Care Accounts, Employee Assistance Program, Tuition Reimbursement and more. Primary Responsibilities: Interface with the billing subcontractor. Work hand in hand with representatives from the billing contractor and the clinic front office to make adjustments in the health record to ensure all activities are billable to all payors. Ensure all client payor information and authorizations are entered into the electronic health record. Reconcile and resolve issues related to claims submissions, research and resolve eligibility issues, including contact with clients to inform of eligibility loss. Ensure all new and ongoing prior authorizations are entered for the Outpatient Clinic programs, Residential Recovery Programs. Ensure all billing to Department of Public Health is entered accurately and in a timely fashion, for the RRS and outpatient clinic programs. Review denials and partially paid claims and resolve discrepancies. Assist in resolving overdue claim problems. Run reports and gather data as needed for financial and operating reports. Recommend write-off and process in billing system as directed. Ensure compliance with program/department, agency and/or funder requirements, as well as, SMOC policies & procedures. Other duties as assigned. Knowledge and Skill Requirements: Associates Degree preferred or relevant experience Medical and/or Mental Health third party billing experience Experience with third party billing denial and resolution process Must have ability to handle multiple and changing priorities and meet deadlines Organizational Relationship: Directly reports to Operations Director. Indirectly reports to Director of Residential Recovery Programs. Direct reports of this position are none. Physical Requirement: Ability to ascend and descend stairs Ability to see and read Ability to lift up to 10lbs Dress is business casual Working Conditions: As part of the responsibilities of this position, the Utilization Management Coordinator will have direct or incidental contact with clients served by SMOC in various programs funded or administered through the Executive Office of Health and Human Services. Remote Work Option: Remote work is permissible in some positions at SMOC depending on the key functions and responsibilities. The Compliance Officer position is eligible to work from home 0-60% of the week in scheduling coordination with the department manager. Monday through Friday: 9:00AM - 5:00PM. Includes a 1-hour unpaid lunch break. 35 Hours per week.

Provides nursing care for pulmonary patients in the ambulatory setting -primarily via telephone and secure messaging, rather than through direct patient contact. The nurse is an integral member of the pulmonary care team in helping patients achieve optimal lung health and in managing chronic conditions effectively - through assessment, planning, treatment and evaluation/re-evaluation. Provides safe, knowledgeable, compassionate, individualized and goal-directed nursing care to patients of the division of Pulmonary, Critical Care & Sleep Medicine at Brown Medicine. PRINCIPAL DUTIES AND RESPONSIBILITIES: Consistently applies the Brown Medicine values of patient care priority, dignity, collaboration, integrity and quality in support of the Brown Medicine mission to deliver compassionate, high-quality patient care, research excellence and outstanding physician education. Is responsible for knowing and acting in accordance with the Brown Medicine Compliance Program and Code of Conduct. Consistently practices the Brown Medicine Customer Service Standards. Provide nursing triage, assessment and education to patients via nurse visits, telephone interactions and secure messaging Manage patient needs including medication management, post procedure instructions and care coordination. Serve as a liaison to patients, family members and referring providers with guidance from pulmonary providers. Acts as patient advocate in the coordination of patient care. Demonstrates understanding and interpretation of diagnostic measures such as lab tests. Identifies goals for the individual patient and communicates these goals to the appropriate care team member involved in the patient's care. Reports and documents information accurately and in a timely manner Seeks guidance, direction and assistance where needed. Adheres to BMED Policy and Procedures at all times and is an active participant in the QI program Adheres to required infection prevention measures and environmental safety practices. Participates in staff meetings and In-services as required/requested. Demonstrates flexibility in patient care, assignment, schedule. Delegate tasks and direct the activities of unlicensed care providers (schedulers, Medical Assistants and Staff Assistants). Utilizing supplies, equipment and resources to contains costs without compromising delivery of care Performs other duties as assigned KNOWLEDGE, SKILLS & ABILITIES REQUIRED: Good command of the English language, both verbal and written. Equivalent mastery of the Spanish language is preferred but not required. Ability to work well with physicians, APPs, employees, patients, families and others. Pulmonary, Nurse Triaging, and/or Ambulatory experience required. EDUCATION AND EXPERIENCE Graduate of a Professional School of Nursing Current state licensure as a registered nurse (RN) or licensed practical nurse (LPN) Current certification in BLS Evidence of continuing education WORKING CONDITIONS AND PHYSICAL REQUIREMENTS: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation(s) may be made to enable individuals with disabilities to perform the essential functions. May have exposure to patients with communicable diseases, blood and body fluids May have exposure to hazardous equipment/gases/chemical agents INDEPENDENT ACTION: Ability to act independently without direct supervision. SUPERVISORY RESPONSIBILITY: None. Reports to: Pulmonary Medical Director/Physician Lead & Practice Manager Employees are required to be vaccinated against Covid as a condition of employment, subject to accommodation for medical exemptions. We value a diverse, talented workplace and seek colleagues who strive to better understand systemic barriers as it affects patient care and our academic institutions. Brown Medicine welcomes nominations and applications from all individuals with varied experiences, perspectives, abilities, identities, and backgrounds to enrich our clinical, research, training and service missions.